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DHSP 532 Revised 10/19/17

ADULT DIAGNOSTIC ASSESSMENT of 7

This confidential information is provided to you in accord with State and Federal laws

and regulations including but not limited to applicable Welfare and Institutions code,

Civil Code and HIPAA Privacy Standards. Duplication of this information for further

disclosure is prohibited without prior written authorization of the client/authorized

representative to whom it pertains unless otherwise permitted by law. Destruction of this

information is required after the stated purpose of the original request is fulfilled.

Name: ID#:

Agency:

Los Angeles County – Division of HIV and STD Programs

Date of assessment ______________

ASSESSING PRACTITIONER (NAME AND DISCIPLINE): _____________________________________

Client/Others Interviewed: ___________________________________________________________________________________________

I. DEMOGRAPHIC DATA & SPECIAL SERVICE NEEDS:

DOB: ______ GENDER: ______ ETHNICITY:____________ Marital Status: __________________________

Referral Source:

Non-English Speaking, specify language used for this interview: _______________________________________________

Were Interpretive Services provided for this interview? Yes No

Cultural Considerations, specify: ___________________________________________________________________________________

Physically challenged (wheelchair, hearing, visual, etc.) specify: __________________________________________________________

Access issues (transportation, hours), specify: _________________________________________________________________________

II. Reason for Referral/Chief ComplaintDescribe PRECIPITATING EVENTS(S)/REASON FOR REFERRAL

CURRENT SYMPTOMS AND BEHAVIORS (INTENSITY, DURATION, ONSET, FREQUENCY) and IMPAIRMENTS IN LIFE

FUNCTIONING caused by the symptoms/behaviors (from perspective of client and others):

CLIENT STRENGTHS (to assist in achieving treatment goals)

SUICIDAL THOUGHTS/ATTEMPTS: “Columbia Suicide Severity Rating Scale Screener (LACDMH Version)”

Wish to be Dead: Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.

1. Within the past 30 days, have you wished you were dead or wished you could go to sleep and not wake up? Yes No

Suicidal Thoughts: General non-specific thoughts of wanting to end one’s life/commit suicide, “I’ve thought about killing myself” without

general thoughts of ways to kill oneself/associated methods, intent, or plan.

2. Within the past 30 days, have you actually had any thoughts of killing yourself? Yes No

If YES to 2, ask questions 3, 4, 5, and 6

If NO to 2, go directly to question 6

Suicidal Thoughts with Method (without Specific Plan or Intent to Act): Person endorses thoughts of suicide and has thoughts of at least

one method during the assessment period.

3. Have you been thinking about how you might kill yourself? Yes No

Suicidal Intent (without Specific Plan): Active suicidal thoughts of killing oneself and patient reports having some intent to act on such

thoughts.

4. Have you had these thoughts and had some intention of acting on them? Yes No


ADULT DIAGNOSTIC ASSESSMENT

of 7







Name: ID#:

Agency:


Suicide Intent with Specific Plan: Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to

carry it out.

5. Have you started to work out or worked out the details of how to kill yourself and do you intend to carry out this plan? Yes No

Suicidal Behavior:

6. Have you done anything, started to do anything, or prepared to do anything to end your life? Yes No

If yes, How long ago did you do any of these?

Additional comments regarding suicidal thoughts/attempts:

Self-Harm (without statement of suicidal intent) Yes No Unable to Assess

If yes, describe

III. MENTAL HEALTH HISTORY/RISKS

History of Problem Prior to Precipitating Event: Include treated & non-treated history.

Impact of treatment and non-treatment history: on the client's level of functioning, e.g., ability to maintain residence, daily living and

social activities, health care, and/or employment.

PSYCHIATRIC HOSPITALIZATIONS: Yes No Unable to Assess

If yes, describe DATES, LOCATIONS, AND REASONS

OUTPATIENT TREATMENT: Yes No Unable to Assess

If yes, describe DATES, LOCATIONS, AND REASONS.

TRAUMA or Exposure to Trauma: Yes No Unable to Assess

Has client ever (1) been physically hurt or threatened by another, (2) been raped or had sex against their will, (3) lived through a disaster, (4)

been a combat veteran or experienced an act of terrorism, (5) been in a severe accident, or been close to death from any cause, (6) witnessed

death or violence or the threat of violence to someone else, or (7) been the victim of a crime?


ADULTDIAGNOSTIC ASSESSMENT of 7







Name: ID#:

Agency:


IV. HIV AND PSYCHOTROPIC MEDICATIONS

Has the client ever taken psychotropic medications? Yes No Unable to Assess

List present medications used, prescribed/non-prescribed, by name, dosage, frequency. Indicate from client's perspective what seems to

be working and not working.

PSYCHOTROPICS DOSAGE/FREQUENCY PERIOD TAKEN EFFECTIVENESS/RESPONSE/SIDE EFFECTS/REACTIONS

Medication Comments (include medication adherence issues/history):

V. SUBSTANCE USE/ADDICTION Screening and Assessment

A. Alcohol Screening Questions 1 Drink = 12 Ounces of beer, 5 Ounces of wine, or 1.5 Ounces of liquor

1. In the past year, how often did you have a drink containing

alcohol?

If “Never”, proceed to Drug Screening Questions.

Never

(0)

Monthly

or less (1)

2-4 times

a month

(2)

3 times

a week

(3)

4+ times a week

(4)

1a. In the past year, how many drinks containing alcohol did

you have on a typical day when you are drinking?

1 or 2

(0)

3 or 4 (1) 5 or 6 (2) 7 to 9

(3)

10+ (4)

1b. In the past year, how often did you have six or more

drinks on one occasion?

Never

(0)

Less than

monthly

(1)

Monthly

(2) Weekly

(3)

Daily or almost

daily (4)

Alcohol Screening Score: __________ (For a score of 4 or more, proceed to Assessment. A brief intervention is also indicated)

Was a brief intervention provided? Yes No

B. Drug Screening Questions (“Yes” to any of the questions below indicates a positive screening)

Ever Used? Recently Used?

(Past 6 Months)

Yes No Yes No

1. Have you used nicotine products? (Cigarettes, cigars, electronic cigarettes, smokeless tobacco)

2. Do you use products containing caffeine, such as tea, coffee or high-caffeine energy drinks?

(Such as AMP, Monster, Red Bull or 5 Hour Energy

3. Have you used opioids? (Heroin, opium, non-prescribed pain medications)

4. Have you used prescription medications, over the counter medications, and/or non-prescription

supplements in a manner other than prescribed? (For example, to get high)

5. Have you used stimulants, such as cocaine or methamphetamine?

6. Have you used drugs intravenously?

7. Have you used drugs/alcohol as a means to engage in sexual activity?

C. Are you interested in changing your substance use patterns? Yes No NA

HIV MEDICATIONS DOSAGE/FREQUENCY PERIOD TAKEN EFFECTIVENESS/RESPONSE/SIDE EFFECTS/REACTIONS

Has the client ever taken HIV medications? Yes No Unable to Assess


ADULT DIAGNOSTICASSESSMENT of 7







Name: ID#:

Agency:


VI. MEDICAL HISTORY

HIV Clinic: _____________________________ PHONE: ___________________ Last Medical Appointment ______________

Major medical problem (treated or untreated) (Indicate problems with check: Y or N for client, Fam for family history.)

Fam Y N Fam Y N Fam Y N Fam Y N

Seizure/neuro disorder Liver disease Hepatitis

Head trauma Renal disease Cancer

Sleep disorder

Cardiovascular disease

Tuberculosis

Asthma/lung disease Hypertension

Weight/appetite chg Gonorrhea Diabetes

Syphilis

ALLERGIES (If Yes, specify):

Sensory/Motor Impairment (If Yes, specify):

Pap smear

If yes, date:

__________

Mammogram

If yes, date:

__________

HIV Test

If yes, date:

__________

Pregnant

If yes, due date:

__________

Comments on above medical problems, co-occurring disorders, recent hospitalizations, etc.

VII. PSYCHOSOCIAL HISTORYPlease state specifically how mental health or HIV status impacts each area below; Be sure to include the client’s strengths in each area.

EDUCATION/SCHOOL HISTORY

Special Education: Yes No Unable to Assess Learning Disability: Yes No Unable to Assess

Motivation, education goals, literacy skill level, general knowledge skill level, math skill level, school problems, etc:

Assessment/Additional Information (answer only if screening is positive)

PAST AND PRESENT USE OF TOBACCO, ALCOHOL, CAFFEINE, CAM (COMPLEMENTARY AND ALTERNATIVE MEDICATIONS)

AND OVER-THE-COUNTER, AND ILLICIT DRUGS, if not determined by screener. Be sure to include route of administration, frequency (amount),

withdrawals, etc.

Herpes









Name: ID#:

Agency:


Yes

LEGAL HISTORYAND STATUS Arrests/DUI, probation, convictions, divorce, conservatorship, parole, child custody, etc:

CURRENT LIVING ARRANGEMENT and Social Support Systems Type of living setting, problems at setting, community, religious, government agency, or other types of support, etc:

DEPENDENT CARE ISSUES

Number of Dependent Adults: ______ Number of Dependent Children: _______ Ages of children, school attendance/behavior problems of children, special needs of dependents, foster care/group home placement issues,

child support, etc:

FAMILY HISTORY/RELATIONSHIPS

History of Mental Illness in Immediate Family: Yes No Unable to Assess

Alcohol/Drug Use in Immediate Family: Yes No Unable to Assess

History of Incarceration in Immediate Family: Yes No Unable to Assess

Family constellation, family of origin, family dynamics, cultural factors, nature of relationships, domestic violence, physical or sexual abuse,

home safety issues, family medical history, family legal/criminal issues

HIV RISK BEHAVIORS/PARTNER SERVICES:

1. Have you had unprotected sex with anyone in the past six months?2. Have you told all of your present and/or past sexual partners your HIV status? Yes No

3. Have you ever used Partner Services? Yes No 4. Yes No

No

Do you want assistance disclosing your HIV status to anyone?









Name: ID#:

Agency:


VIII. MENTAL STATUS EVALUATION

Instructions: Check all descriptions that apply

General Description Mood and Affect Thought Content Disturbance Grooming & Hygiene: Well Groomed

Average Dirty Odorous Disheveled Bizarre

Comments:

Eye Contact: Normal for culture Little Avoids Erratic

Comments:

Motor Activity: Calm Restless Agitated Tremors/Tics Posturing Rigid

Retarded Akathesis E.P.S.

Comments:

Speech: Unimpaired Soft

Slowed Mute Pressured Loud

Excessive Slurred Incoherent Poverty of Content

Comments:

Interactional Style: Culturally congruent Cooperative Sensitive

Guarded/Suspicious Overly Dramatic

Negative Silly Comments:

Orientation: Oriented

Disoriented to: Time Place Person Situation

Comments:

Intellectual Functioning: Unimpaired Impaired

Comments:

Memory: Unimpaired Impaired re: Immediate Remote Recent

Amnesia

Comments:

Fund of Knowledge: Average Below Average Above Average

Comments:

Mood: Euthymic Dysphoric Tearful

Irritable Lack of Pleasure Hopeless/Worthless Anxious

Known Stressor Unknown Stressor

Comments:

Affect: Appropriate Labile Expansive

Constricted Blunted Flat Sad

Worried Comments:

Perceptual Disturbance None Apparent

Hallucinations: Visual Olfactory Tactile Auditory: Command

Persecutory Other

Comments:

Self-Perceptions: Depersonalizations

Ideas of Reference

Comments:

Thought Process Disturbances None Apparent

Associations: Unimpaired Loose

Tangential Circumstantial Confabulous

Flight of Ideas Word Salad

Comments:

Concentration: Intact Impaired by:

Rumination Thought Blocking Clouding of Consciousness Fragmented

Comments:

Abstractions: Intact Concrete

Comments:

Judgments: Intact Impaired re: Minimum Moderate Severe

Comments:

Insight: Adequate Impaired re: Minimum Moderate Severe

Comments:

Serial 7’s: Intact Poor

Comments:

None Apparent

Delusions: Persecutory Paranoid Grandiose

Somatic Religious Nihilistic

Being Controlled Comments:

Ideations: Bizarre Phobic Suspicious

Obsessive Blames Others Persecutory Assaultive Ideas Magical Thinking

Irrational/Excessive Worry

Sexual Preoccupation Excessive/Inappropriate Religiosity

Excessive/Inappropriate Guilt

Comments:

Behavioral Disturbance

Behavioral Disturbances: None Aggressive

Uncooperative Demanding Demeaning Belligerent Violent Destructive

Self-Destructive Poor Impulse Control

Excessive/Inappropriate Display of Anger Manipulative Antisocial

Comments:

Suicidality/Homicidality

Suicidal: Denies Ideation Only

Threatening Plan

Comments:

Homicidal: Denies Ideation Only

Threatening Target Plan Comments:

Other

Passive: Amotivational Apathetic

Isolated Withdrawn Evasive Dependent

Comments:

Other: Disorganized Bizarre

Obsessive/compulsive Ritualistic

Excessive/Inappropriate Crying Comments:


ADULT DIAGNOSTICASSESSMENT of 7







Name: ID#:

Agency:


IX. Summary and Diagnosis

1. CLINICAL FORMULATION: (Be sure to include assessment of risk of suicidal/homicidal behaviors, significant

strengths/weaknesses, observations/descriptions, symptoms/impairments in life functioning, i.e. Work, School, Home Community,

Living Arrangements, etc, and justification for diagnosis)

2. DIAGNOSTIC DESCRIPTOR ICD DIAGNOSIS CODE (check at least one Primary)

_______________________________________________ Primary Code __________

_______________________________________________ Sec Code __________

_______________________________________________ Code __________

_______________________________________________ Code __________

_______________________________________________ Code __________

_______________________________________________ Code __________

_______________________________________________ Code __________

_______________________________________________ Code __________

_______________________________________________ Code __________

3. Does client's mental health status interfere with HIV medical care? Yes No

4. Disposition/Recommendations/Plan

5. SIGNATURE

__________________________________ __________ ________________________________ __________ Assessor’s Signature & Discipline Date Co-Signature & Discipline Date

HIV Medical Care Goals

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